The Disqualifier

The couple desperately needed health insurance.  Their current health policy, purchased through COBRA, was about to end and the woman was pregnant.  She was a former banker and he was a private money manager.  Even though I had found a way to solve their problem, they still had one question to ask me before they would allow me to help them.

“What type of annuities do you sell”?

There were some really terrible annuities on the market twelve years ago and they viewed the sales of these products as a disqualifier.  It wasn’t a problem for me.  I didn’t sell any annuities, the good or the bad ones.  They are still clients.

We all have disqualifiers, reasons why we won’t do business with certain people or companies.  Some are logical.  Some aren’t.  Some, like the example above, speak to an individual’s honesty and professionalism.  And some disqualifiers are simply excuses covering a darker motivation.

This edition of Health Insurance Issues With Dave will address my Number 1 disqualifier – REFERRALS.

The insurance companies are under intense pressure to control health care costs.  The Patient Protection and Affordable Care Act (PPACA) has instituted a number of changes in the marketplace.  Many of these changes have negatively impacted the way the insurers price and market their products.  The very design of the new policies can, at times, seem counterproductive.  Finding a way to control costs is a major priority.  Many insurers have embraced the concept of requiring referrals.

How does this work?  When you purchase a policy through some carriers you will be required to name a Primary Care Physician (PCP).  We are used to this procedure with a Health Maintenance Organization (HMO) such as HealthSpan, the former Kaiser Permanente.   But in this example we are talking about a traditional network driven PPO (Preferred Provider Organization).  It has been about twenty years since this was common in our area.

Your Primary Care Physician serves as your health care quarterback.  You will need a referral from him/her to have any treatment by a specialist, lab, or facility covered by your policy.  No referral – no coverage.

Your first question might be, “How much will my family doctor be paid for this additional responsibility and paperwork?”  The answer is NOTHING.  The government is projecting a shortage of over 20,000 primary care doctors in the next five years.  More and more services are being provided by physicians’ assistants and nurse practitioners.  Weighing down physicians with uncompensated paperwork is not a good idea.

What happens once you get your referral?  Let’s skip the issue of fighting to be referred to the doctor of your choice.  We’ll pretend that you have diabetes and that your doctor (Smith) is willing to refer you to your family’s endocrinologist (Jones).  Dr. Jones conducts a thorough examination and decides that he needs a few more tests and that you should see the ophthalmologist (Swenson).  Dr. Jones isn’t authorized to refer you and you can’t just make an appointment.  If you want the visits covered you will need to return to Dr. Smith to secure another referral.  And another.  And another.

Is the insurer hoping to control costs by eliminating unnecessary doctors’ visits and tests or is the goal to sidestep the payment of unauthorized care?  That’s what it looked like the last time this practice raised its ugly head.

You are your best advocate.  You should be in charge of your health care.

I refuse to market any non-HMO policy that requires a referral to see specialists.  Many of these policies are purchased by the unsuspecting public through healthcare.gov.  It is very difficult to determine whether a policy requires referrals if you are buying a policy on the government’s exchange without an agent present.  Too many will not find this out until their claims are denied.

I see the healthcare.gov problem as a sin of omission rather than a sin of commission.  But sin is sin.  It’s a disqualifier.